We still don't know what patients value

Great systematic review in PLoS One [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498685/] regarding self-management outcomes. Basically, long term chronic illnesses mean that self-management is crucial, but we don't seem to do enough research about what patients actually value. Great article. My selected highlights are as follows;
"Patients in our review identified that receiving support for self-management which is meaningful and relevant to the context of their lives is an important outcome. However, services often focus upon process driven outcomes, such as length of stay, or change in blood glucose, without necessarily considering the meaningfulness of this for the patient."
"few studies explicitly identified families’ perspectives".

We are left we the interesting problem, of how we can train physicians to better elicit the values of the their patients. Indeed, it begs interesting questions about what values health professionals bring to their work and practice. 

Violence against health care workers - exploring why patients do it

The American Medical Association (AMA) is to support more research to find interventions to help deal with violence against health care workers. The statistics are quite revealing. According to the Bureau of Labour Statistics in the US health care workers experience the most nonfatal workplace violence compared to other professions, with attacks at hospital and social service settings accounting for almost 70 percent of nonfatal workplace assaults.

Research suggests that health-care workers are hit, kicked, scratched, bitten, spat on, threatened and harassed by patients with surprising regularity (especially nurses). The current health care environment often requires that health care workers maintain optimal performance even in the immediate chaotic aftermath of workplace violence. Workplace violence prevention has not been given the priority it rates.

The rates of violence in both developing and developed countries strongly suggest that the problem is a system issue, and not a small minority.

Violence may represent an opportunity to revaluate the degree to which we involve patients and the public in healthcare delivery, healthcare policy and healthcare research. Health care workers must be appalled that individuals are ‘fighting’ against the people trying to help them, but answering such questions may help to provide a more ‘patient’ view of the healthcare journey. We can’t seem to really involve patients and the public (for a myriad of reasons), and the violence issue is part of this.  

How Physicians react to complaints

Using a large data set of 7926 doctors, a paper in BMJ Open* sheds some interesting light on how complaints affect doctors. The response rate was low (8.3%), so conclusions have to be interpreted with caution. That said, some of the highlights of study were:
- Of doctors who had a recent complaint (of any kind) 77%  were more likely to suffer from moderate to severe depression than those who have never had a complaint. They also have double the risk of having thoughts of self-harm and double the risk of anxiety.
-  80% of doctors answering the survey reported changing the way they practiced as a result of either complaints against themselves, or after observing a colleague go through a complaints process.

It's a cross sectional paper, so its difficult to establish any casual link. For example, it is possible that doc's suffering from mental health problems may be more likely to have complaints made against them.
Anyway, interesting paper, limitations aside.

* Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2015;4:e006687. doi:10.1136/bmjopen-2014- 006687

Should physicians wear white coats?

Does physician attire influence patient trust and satisfaction? A 2015 systematic review in BMJ Open [BMJ Open 2015;5:e006578. doi:10.1136/bmjopen-2014-006578] suggests wide variability in preferences, and difficulty in reaching robust conclusions. However, a fine grained reading of the paper highlights some interesting findings:

1.    Patients who received clinical care were less likely to voice preference for any type attire than patients that did not

2.    Studies that included physician encounters were less likely to find specific preferences (3/12 studies) compared to studies conducted outside of a physician–patient meeting (18/18 studies).

3.    Studies originating from the UK, Asia, Ireland and Europe most often expected formal attire with or without white coats (especially among older people.

So, conclusions 1 and 2 seem to suggest that issues concerning physician attire become less important as the patient experience becomes more real.

Is technology the enemy of patient history taking?

No one doubts the potential for technology to aid medical decision making and the organization of health systems. However, there is a thought provoking viewpoint in JAMA [http://jama.jamanetwork.com/article.aspx?articleid=2020379] on the potential downside to Electronic Health Records (EHR). The authors use the idea of the 'flipped' patient to argue that EHRs may degrade history taking. To quote the authors; "For a generation for whom texting can be more intimate than face-to-face conversation, there might be an assumption that the EHR is the dialogue with the patient, not a representation of one." Food for thought for any teaching medical students.

HPs perceptions of clinical governance

Great paper in the latest issue of BMJ Open [Gauld R, et al. BMJ Open 2015;5:e006157. doi:10.1136/bmjopen-2014-006157] on HP perceptions of clinical governance in New Zealand. The response rate was 25%, but the results are instructive.  Five key themes illustrating barriers to clinical governance implementation were found, representing problems with: developing management–clinical relations; clinicians stepping up into clinical governance and leadership activities; interprofessional relations; training needs for governance and leadership; and having insufficient time to get involved.

Interestingly, only 47% respondents said they were ‘familiar’ or ‘very familiar’ with the concept of clinical governance. 

Healthcare organizations are populated by educated and motivated people, so the results of the paper seem to suggest that there is a problem with a common/shared vision?

Medical students’ view about deceiving patients with dementia

Dementia is set to become one of the major challenges of the next 50 years, in both the developed and developing world. In a 2014 paper in Aging and Mental health [Aging & Mental Health, 2014 http://dx.doi.org/10.1080/13607863.2014.967173] students expressed uncertainty as to their ability to make judgments about honest communication with patients with dementia and their families. In this very interesting qualitative study, the researchers found that whilst students recognised the importance of the autonomy of each individual with dementia, they expressed difficulties with determining an individual’s‘best interests’ in isolation. Students commented on the apparent mismatch between rule based ethical ideals, as promoted in formal documents about professionalism, and the complexities that they had seen in practice. They expressed anxiety about their own ability to interpret professional guidelines and act in the best interests of individual patients at all times. This is a great paper for both researchers and as a teaching tool. 

Solving global health problems and healthcare

Do the solutions for global health lie in healthcare? A recent analysis article in the BMJ [BMJ 2014;349:g5457 doi: 10.1136/bmj.g5457] should be sobering reading for all of us. The author Jocalyn Clark reminds us to why putting all our money on healthcare to solve global health problems is doomed to failure. The article does a fine job in arguing why we need to find creative solutions that integrate healthcare into the equation. My own take on the piece is that is has interesting implications for how we train and educate doctors. I will be distributing copies of it to the clinicians that I teach, and exploring their reactions to its implications. 

Safety and quality are not necessarily the same thing!

An excellent article in BMJ Open [Mumford V, et al. BMJ Open 2014;4:e005284. doi:10.1136/bmjopen-2014-005284] reveals how safety and accreditation processes can travel in different directions. The study involved a longitudinal comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals. The most interesting aspect of the study was that higher accreditation scores as reflected in hand hygiene rates appears to be confounded by an accreditation programme that makes it more difficult for smaller hospitals to achieve high infection control scores. Basically, smaller hospitals (with good hand hygiene scores) failed to score well on the accreditation programme due to organizational size. As the authors conclude themselves; “In this study, a focus on the accreditation results would underestimate the successful implementation of the hand hygiene policy by smaller hospitals. Conversely, just using hand hygiene results would underestimate the research and leadership investment in infection control by larger hospitals.”

Disruptive behaviour among physicians; a few bad apples or the whole barrel?

I am reviewing the literature on disruptive behaviour among physicians, and the Leape et al (2012) article stands out as one worth reading [Acad Med. 2012;87:845–852. doi: 10.1097/ACM.0b013e318258338d]

Some of their conclusions are worth repeating;
"We believe, however, that the fundamental cause of our slow progress is not lack of know-how or resources but a dysfunctional culture that resists change. Central to this culture is a physician ethos that favors individual privilege and autonomy—values that can lead to disrespectful behavior."

"Students and residents suffer from disrespectful treatment. “Education by humiliation” has long been a tradition in medical education and still persists."

While other authors in the field are a bit too focused on repeat offenders (which is a worthy topic), Leape et al provide a cogent series of arguments that should force us to look at the system issues that contribute doc's behaving badly.

The implications for patient safety come screaming out at us......

Why do surgery residents want to leave their programmes?

An interesting US study [JAMA Surg. doi:10.1001/jamasurg.2014.935] looking at the reasons why general surgery residents want to leave their programmes reveals how more than half seriously consider leaving the program. Notable among the reasons was an undesirable future lifestyle, which chimes with the research on burnout and work-home conflict. Also, women were more likely to report wanting to leave. Factors most often cited that kept residents from leaving were support from family or significant others (65.0%), support from other residents (63.5%), and perception of being better rested (58.9%). Ultimately, the high percentage of residents who express a desire to leave should prompt us to consider how we can rethink residency training. The authors didn’t measure patient outcomes, but one wonders whether those who want to leave treat patients differently?

guides for new docs- what does it say about the culture of medicine?

The BMJ guide for newly qualified doctors is well written and packed with useful information.
It can be downloaded at http://doc2doc.bmj.com/assets/secure/youwillsurvive.pdf
However, if we step back and take a more panoramic view, does it tell us something more interesting about the culture of medicine and the values that it represents?
The guide it titled 'You will Survive', and page 2 starts with the sentence "The first day will always be frightening says junior doctor......."
The overall tone of the guide is that new doctors are going to feel out of their depth and under great levels of stress. The interesting question is to what degree the tone of the guide reinforces the notion that feeling overwhelmed should be considered normal. Preparing doctors to accept that being stressed is the norm and that feeling terrified is acceptable makes it less likely that they will ever question whether healthcare can be delivered in a radically different way.
It's obvious that guide is useful, but does it get the individuals to focus on themselves rather than the system they inhabit?

What kind of doctors have difficulty asking for help?

Doctors who male, older or suffering from addictions have greater difficulties when asking for help from a Physicians’ Health Program. Very interesting study from a team from Barcelona. 
http://bmjopen.bmj.com/content/4/7/e005248.full.pdf+html

Greater professional empathy leads to higher agreement about decisions made in the consultation

Interesting study about empathy in the consultation process.  See the article at http://www.sciencedirect.com/science/article/pii/S0738399114001827
In the study, empathic responses to statements of challenge were found to be a strong predictor of agreement and resulted in both parties reporting and agreeing on more decisions. 
In particular, I liked the fact that empathy can be communicated by simply acknowledging the other. 

The inevitability of physician burnout: Implications for interventions

For physicians, burnout is the inevitable consequence of the way that medical education is organised and the subsequent maladaptive behaviours that are reinforced in healthcare organisations via the hidden curriculum. Thus, burnout is an important indicator of how the organisation itself is functioning. I have written a paper about the issue;
http://www.sciencedirect.com/science/article/pii/S2213058614000084
A central theme of paper is the degree to which the organisational systems are responsible for the disconnect between performance and physician health. Healthcare pays considerable ‘lip-service’ to systems approaches, but in practice it valorises the role of the individual physician in terms of both success and failure. Thus, this contradiction needs to be addressed.

Duty hours of residents don’t seem to make a systematic difference!!

It’s hard not reach this conclusion after reading the 2011 review concerning Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules [J Gen Intern Med 26(8):907–19]. The authors warn us about comparing apples with oranges but the lack of any overall pattern regarding the impact on patients and residents is striking. For example, medical and surgical complications were interesting, with some improving and others worsening. The authors try to explain such differences as a product of less exhausted residents or worse continuity of care etc...As noted by the authors, the greatest limitation of the review is that conclusions rest upon studies demonstrating association, not causality. The authors collate a considerable amount of information, but the review (as acknowledged by the authors) doesn’t succeed in communicating the context. 

GPs decision making

A BMJ Open paper [BMJ Open 2013;3:e002982. doi:10.1136/bmjopen-2013-002982] evaluated compliance on treatment recommendations from clinical practice guidelines in their decisions on the management of heart failure patients. This was a vignette study with 451 Dutch GPs (but statistical power was weakened by low number of doctors that followed the recommendations). Maybe the most interesting results were; the fact that none of the 451 GPs took the four optimal decisions presented and that none of the relevant doctor characteristics was related to doctor compliance with clinical practice guidelines recommendations on all four treatment decisions. Obviously something else is at work here, but what?

What is the purpose of medical education?

There is an engaging article in the recent issue of medical education [MEDICAL EDUCATION 2013; 47: 942–949]. It’s actually an email dialogue between  Dr David Hirsh and Professor Paul Worley. They attempt to address three important questions; Who are medical schools for? What is medical education for? What is the telos (the ultimate aim) of medical education? There is a lot of rich material in the exchange and I can’t do it proper justice here, but I will select out the elements that I liked best:

1.    The goals and purpose of medical education should be community engaged. Thus, communities should be co-creators of the curriculum and its delivery.

2.    There is a need to move beyond student-centeredness in medical education.

3.    The article highlights Cuba and the Barrio Adentro programme in Venezuela as exemplars of community engagement, and suggests that such models could fuel discovery and innovation.

4.    The final line of the paper is quotable; “The systemic result is that the goal of transforming medical education to repair society may actually transform us!”

These are just four parts that I liked; the paper is definitely worth a read. It’s rare that we see a paper exploring the values needed in medical education

Contradictions between resident education and patient safety?

A recent JAMA paper [JAMA INTERN MED/VOL 173 (NO. 8), APR 22, 2013] reports on a randomised experiment that compares between the 2003 and 2011 duty hour restrictions for US residents. The 2011 rules mandate rest periods between duty periods, increased supervision for junior trainees, and a 16-hour limit on continuous duty hours for postgraduate year 1 (PGY-1) trainees (interns). In a nutshell, the new regulations equal more work compression. Compared with a 2003- compliant model, two 2011 duty hour regulation– compliant models were associated with increased sleep duration during the on-call period, but with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Viewing the paper from an organisational psychology perspective, there is a very bizarre narrative going on. There is an overwhelming sense in the paper that we can’t really shorten the hours of residents, and it almost reads like a ‘I told you so!!’ (my interpretation not the authors). Indeed, the authors cite many studies in their conclusion section that found similar results. Additionally, the new system increased handoff related mistakes.  Speaking as a non-physician, the important issue that was screaming out was; WHY ARE HOSPITALS/HEALTHCARE ORGANISED IN THIS WAY? This is a complicated question, but rather than getting everybody focused on more sleep for residents (which is desirable), I want to know the vision and values of everybody at these hospitals. I can imagine that the healthcare professionals are increasingly prompted towards self-preservation rather than a meaningful balance between patient safety and healthcare well being. Finally, there is a really interesting contradiction between less educational opportunities and time. So rather than having meaningful discussions about the way that residents spend their time (in educational terms), we are forced to accept that the system is that way it is. Physicians reading my opinions may be thinking the same way (i.e., we can’t really change the system), but surely the paper suggests that there is no other alternative but to reimagine the system. Let’s get serious about analysing the systems

Do physicians need empathy?

The answer depends on the papers you read. A 2011 paper [Acad Med. 2011;86:359–364.] found that higher empathy was related to better clinical outcomes for diabetic patients. Good news, yes? Well, it seems so until you read the paper and discover that the research was based in a sample of 29 family physicians (but 891 patients). The paper had good methodology but how far can we get with 29 people? In contrast to this, a 2012 paper [Medical Teacher- 2012; 34: e116–e122] looking at the importance of empathy on changing specialty among medical students (858/1321 students from 5 medical schools) found that is wasn't important and changed little over the course of one year. Finally,  a 2013 paper [Medical Teacher-2013; 35: e946–e951] examined empathy among 72 medical students longitudinally (during 5^th and 6^th year). The study threw two interesting findings; (1) students were reported less empathy over time, which the authors report as being due to additional clinical responsibility, more patient contact and more management decisions, and (2)  students who self-rated as having more empathy received lower competence evaluations  from their peers. In my opinion (not the authors), it sounds like the organisation is very effectively teaching them that empathy is not so important.

Three very different studies, with the first one relating to family physicians and the second two concerning medical students. Difficult to know what to conclude, but food for thought none the less. If we actually reinforce medical students not to be have empathy, maybe we should ask why?